Response to: Measuring Under- and Over- Use of Medications

We thank Drs. Hanlon and Schmader for their response to our paper,¹ which provides a framework for evaluating medication appropriateness in older adults and argues for caution in adding medications to the regimens of vulnerable older adults. Their comments highlight that we were not clear in our summary of the evidence regarding interventions for polypharmacy. No studies exclusively addressing potential prescribing omissions (PPOs) have included clinical outcomes. We note that, while the outcome of adverse drug reactions (ADRs) included in their study² may sometimes result from a PPO, it is much more commonly a consequence of potentially inappropriate medications (PIMs). This outcome therefore does not directly address the clinical effects of addressing medication underuse

We appreciate the additional information regarding updating of criteria for identifying PPOs and PIMs. The medications for which our paper presents data on their adverse effects in vulnerable older adults are included in the updated START criteria.³ There will be ongoing debate and argument about the details regarding PPOs and PIMs, which can only serve to strengthen the criteria by which these medications are identified. In the meantime, the development of the STOPPFrail criteria⁴ underlines the growing appreciation of a narrowed or absent therapeutic benefit of a range of medications among frail and otherwise vulnerable older adults.